1710025200 NPI number — CLARK CHIROPRACTIC CENTER, INC.

Table of content: (NPI 1710025200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710025200 NPI number — CLARK CHIROPRACTIC CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARK CHIROPRACTIC CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710025200
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4639 MOUNTAIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21122-5455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-637-4936
Provider Business Mailing Address Fax Number:
443-637-4946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4639 MOUNTAIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21122-5455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-637-4936
Provider Business Practice Location Address Fax Number:
443-637-4946
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
443-637-4936

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1464PT , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com